Aspirin

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After 120 years, aspirin remains an important medication in the acute treatment of vascular events, after certain procedures, in secondary prevention, and in primary prevention in the right patients.

Health & Medicine

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Arrythmia-IV.pptx

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A 57-year-old male presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had a higher refractory period than the atrioventricular node.

Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway a...

Ramachandra Barik

Anticoagulation therapy during pregnancy

Ramachandra Barik

Percutaneous balloon dilatation, first described by Andreas Gruentzig in 1979, was initially performed without the use of guidewires.1 The prototype balloon catheter was developed as a double lumen catheter (one lumen for pressure monitoring or distal perfusion, the other lumen for balloon inflation/deflation) with a short fixed and atraumatic guidewire at the tip. Indeed, initially the technique involved advancing a rather rigid balloon catheter freely without much torque control into a coronary artery. Bends, tortuosities, angulations, bifurcations, and eccentric lesions could hardly, if at all, be negotiated, resulting in a rather frustrating low procedural success rate whenever the initial limited indications (proximal, short, concentric, noncalcified) were negated.2 Luck was almost as important as expertise, not only for the operator, but also for the patient. It is to the merit of Simpson who, in 1982, introduced the novelty of advancing the balloon catheter over a removable guidewire, which had first been advanced in the target vessel.3 This major technical improvement resulted overnight in a notable increase in the procedural success rate. Guidewires have since evolved into very sophisticated devices.

Coronary guidewire

Ramachandra Barik

Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mm×3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant

Intracoronary optical coherence tomography

Ramachandra Barik

Brugada syndrome (BrS) is an inherited cardiac disorder, characterised by a typical ECG pattern and an increased risk of arrhythmias and sudden cardiac death (SCD). BrS is a challenging entity, in regard to diagnosis as well as arrhythmia risk prediction and management. Nowadays, asymptomatic patients represent the majority of newly diagnosed patients with BrS, and its incidence is expected to rise due to (genetic) family screening. Progress in our understanding of the genetic and molecular pathophysiology is limited by the absence of a true gold standard, with consensus on its clinical definition changing over time. Nevertheless, novel insights continue to arise from detailed and in-depth studies, including the complex genetic and molecular basis. This includes the increasingly recognised relevance of an underlying structural substrate. Risk stratification in patients with BrS remains challenging, particularly in those who are asymptomatic, but recent studies have demonstrated the potential usefulness of risk scores to identify patients at high risk of arrhythmia and SCD. Development and validation of a model that incorporates clinical and genetic factors, comorbidities, age and gender, and environmental aspects may facilitate improved prediction of disease expressivity and arrhythmia/SCD risk, and potentially guide patient management and therapy. This review provides an update of the diagnosis, pathophysiology and management of BrS, and discusses its future perspectives.

Brugada syndrome

Ramachandra Barik

The Human Developmental Cell Atlas (HDCA) initiative, which is part of the Human Cell Atlas, aims to create a comprehensive reference map of cells during development. This will be critical to understanding normal organogenesis, the effect of mutations, environmental factors and infectious agents on human development, congenital and childhood disorders, and the cellular basis of ageing, cancer and regenerative medicine. Here we outline the HDCA initiative and the challenges of mapping and modelling human development using state-of-the-art technologies to create a reference atlas across gestation. Similar to the Human Genome Project, the HDCA will integrate the output from a growing community of scientists who are mapping human development into a unified atlas. We describe the early milestones that have been achieved and the use of human stem-cell-derived cultures, organoids and animal models to inform the HDCA, especially for prenatal tissues that are hard to acquire. Finally, we provide a roadmap towards a complete atlas of human development.

A roadmap for the human development

Ramachandra Barik

The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists, reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure.

Intra aortic balloon pump

Ramachandra Barik

Left ventricular false tendons (LVFTs) are fibromuscular structures, connecting the left ventricular free wall or papillary muscle and the ventricular septum. There is some discussion about safety issues during intense exercise in athletes with LVFTs, as these bands have been associated with ventricular arrhythmias and abnormal cardiac remodelling. However, presence of LVFTs appears to be much more common than previously noted as imaging techniques have improved and the association between LVFTs and abnormal remodelling could very well be explained by better visibility in a dilated left ventricular lumen. Although LVFTsmay result in electrocardiographic abnormalities and could form a substrate for ventricular arrhythmias, it should be considered as a normal anatomic variant. Persons with LVFTs do not appear to have increased risk for ventricular arrhythmias or sudden cardiac death.

Left ventricular false tendons

Ramachandra Barik

The optimal management of bifurcation lesions has received significant interest in recent years and remains a matter of debate among the interventional cardiology community. Bifurcation lesions are encountered in approximately 21% of percutaneous coronary intervention procedures and are associated with an increased risk of major adverse cardiac events. The Medina classification has been developed in an attempt to standardise the terminology when describing bifurcation lesions. The focus of this article is on the management of the Medina 0,0,1 lesion (‘Medina 001’), an uncommon lesion encountered in <5% of all bifurcations. Technical considerations, management options and interventional techniques relating to the Medina 001 lesion are discussed. In addition, current published data supporting the various proposed interventional treatment strategies are examined in an attempt to delineate an evidence-based approach to this uncommon lesion.

Approach to medina 001 bifurcations

Ramachandra Barik

Drug resistance is defined as the lack of expected response to a standard therapeutic dose of a drug or as resistance resulting from biologic changes in the target, as occurs in antibiotic resistance. Heparin resistance, the failure to achieve a specified anticoagulation level despite the use of what is considered to be an adequate dose of heparin, is neither well understood nor well defined. Heparin resistance usually refers to an effect of unfractionated heparin, for which doses are measured and adjusted, rather than low-molecular-weight heparin, which is not routinely monitored with laboratory testing. Although it is infrequently invoked in inpatient settings, heparin resistance has been reported in critically ill patients with coronavirus disease 2019 (Covid-19) who are at high risk for thrombosis.1-3 This review provides a clinical summary of heparin resistance and potential management strategies.

Heparin resistance

Ramachandra Barik

Congenital cardiac surgery is one of the most challenging and fascinating branches of modern medicine which continues to advance in areas and improving outcomes, post-operative and pre-operative care. Patent Ductus Arteriosus was the first congenital heart lesion to be successfully corrected surgically. The landmark surgery was performed by Dr. Robert E. Gross in 1938 and opened up the possibility of subsequent surgical correction of various other lesions, which were considered to be untreatable previously. The first successful surgical closure of persistent ductus arteriosus (PDA) was preceded by years of work and contributed by various surgeons, physicians, and anatomists, dating all the way back to the 1st century. They are all worthy of recognition and praise. This article covers the important events related to PDA lesions including its first identification, followed by its description in various texts and sources over the course of time, failed attempts at surgical correction, and disputes regarding credits. These contributions to the branch cannot be overstated and serves as an inspiration to cardiac surgeons all over the world and to students, interns, and newly graduated doctors as well, who would one day like to be part of this fascinating branch.

Surgical repair of patent ductus arteriosus history timeline

Ramachandra Barik

Origin and migration of T and B cells. Hemopoietic stem cells originating in the yolk sac, fetal liver, or bone marrow migrate through the blood to the thymus, where they differentiate into T lymphocytes. Others differentiate within the bone marrow in mammals, or the bursa of Fabricius in birds, to produce B cells. Mature T and B cells circulate in the blood and lymph and colonize the T and B cell compartments of the lymphoid tissues

The function of the thymus

Ramachandra Barik

Isolated monomorphic premature ventricular complexes (PVCs) without structural heart disease are generally benign. ► Frequent PVCs can cause reversible cardiomyopathy or aggravate an existing cardiomyopathy. ► Short coupled PVCs can trigger sustained ventricular fibrillation. These are often from the Purkinje tissue or rarely the outflow tract. ► Beta blockers are considered first-line therapy but have low efficacy. Catheter ablation and AADs are reasonable to suppress PVCs in appropriate patients. ► Ablation is often curative and success depends on location and accessibility of PVCs. ► Implantable defibrillators are reasonable in patients at higher risk of sudden cardiac death.

Management of premature ventricular complexes

Ramachandra Barik

This article reviews the role of invasive hemodynamics in the care of patients across the entire spectrum of human heart failure.  Conceptual principles of ventricular function, ventricular-arterial interaction, load response, and ventricular interaction in the right and left heart are reviewed.  Principles and practice of invasive exercise testing are provided, along with detailed discussions on the role of invasive hemodynamics in the evaluation and management of advanced heart failure, shock, mechanical circulatory support, and pulmonary hypertension.

Hemodynamics for the heart failure

Ramachandra Barik

Significant unprotected left main (LM) coronary artery disease is present in <10% of patients undergoing coronary angiography. In autopsy research, a mean LM length of 10.8 mm ± 5.2 mm (range 2–23 mm), mean LM diameter 4.9 mm ± 0.8 mm and mean angle between the left anterior descending (LAD) and left circumflex (LCx) of 86.7° ± 28.8° has been described. This angle value positively correlated with LM length.2 Further studies showed that long LM developed stenoses more frequently near the distal bifurcation compared to near the ostium (77% versus 18%).7 It is also worth emphasising that LM bifurcation disease is rarely focal and that both sides of the carina are almost never disease-free. Furthermore, continuous plaque from the LM into the proximal LAD artery has been reported in 90% of cases.8 Summarised below are the most crucial LM peculiarities (in comparison with non-LM bifurcations), which should be taken into consideration when distal LM stenosis PCI is planned:

Bifurcation stenting

Ramachandra Barik

Valve in-valve implantation into a failed mechanical prosthetic aortic valve

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Approach to medina 001 bifurcations

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